Mar 12, 2026 11:58

To: +16042339777 From: Foremed Medical Clinic

Page: 03/46
Fax Server 2/23/2026 9:58:11 AM PST PAGE 2/005 Fax Server

TO:Dr. Ademiluyi COMPANY:

SAFE BC | Web < Malling Address, Fax Cali Gantre
| WoRK| WIE WOTKSEFERC.CUM ory 655 a7qy Sts Terma 604 289-9777 804 21 -anae

Vancouver SG. VOe HOO? a7F
WORKING TO MAKE DIFFERENCE rarcouwer OC VBE 14 1 BBD 928-8 4 60 867 62

February 23, 2026

DR. ADEMILUY!

FOREMED CLINIC

420 COLUMBIA ST

NEW WESTMINSTER BC V34 181

To the Health Care Provider:

REGARDING: MARK HOLAND

DATE OF INJURY: January 12, 2026

PERSONAL HEALTH CARE NUMBER: 9128549738
DATE OF BIRTH: September 04, 1978
WORKSAFEBC CLAIM NUMBER 42647461

The above-named worker has filed a claim for compensation for an injury sustained on
January 12, 2026.

Plaase provide a copy of all previous chart notes relating to migraines & bilateral ears
that covers the date from January 1%, 2621 to current date. Please include capies of
all radiological, consultation reports, results of tests that may have been
undertaken such as EMG, MRI, X- Rays, U/S, CT scans etc.

Under beth the Workers Compensation Act and the Freedorn of Information and
Protaction of Privacy Act, WorkSateBC is given autharity to receive all medical
information pertaining to this worker that is considered necessary for the adjudication of
the claim.

A copy of the worker's authorization for the release of ihis medical information is
attached.

Enclosed is the Request for Severed Physician/Psychiatrist Records. The form includes
the appropriate code and fee items as per the fee structure agreed on by your
association and WorkSafeBC.

Use the allached request form as your cover sheet. This will ensure a timely submission
to the worker's claim file. Include the worker's name and claim number on all pages
submitted.

PLEASE INCLUDE CLAIM OR ACCOUNT NUMBER IN ALL CORRESPONDENCE

of British Columbia
Mo -u

Workers’ Comper
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Fax: 16043985614

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